New ED nurse

PedNephNurse · Sep 2, 2016

I give full props to ER nurses. They are amazing. It is completely normal to feel the way you do. If you weren't feeling that way then something wouldn't be right. Always ask questions, take every opportunity to practice a skill or learn a new one, research things in your spare time to help you understand new concepts. Get a little notepad to take quick notes down that you can fit in your pocket. I like to know how to look up protocols so if I have something pop up that I know I learned at one point but can't fully remember I can refresh my memory. Before you know it you'll be just like the other seasoned ER nurses. Any nursing experience we gain never goes wasted. You'll be surprised how your OB knowledge will come in handy from time to time!

jv713 · Sep 3, 2016

thanks so much for responding! i figured some people probably felt this way but i am so bad at comparing myself to others.. when i look at others from my training group some feel way more confident than me and it gets to me. again, I'm probably too hard on myself but sometimes its hard not to be. i want to be as good as the other seasoned nurses in the ER so bad so ill have to keep pushing myself. and i like your idea of the little notebook, i think ill have to try that. i made a little "brain sheet" that i will try to utilize next time i work to see if that will help with the organization

GM2RN · Sep 3, 2016

PedNephNurse is absolutely right; it's normal to feel overwhelmed at first, and expect to feel that way for awhile, but it does get better! I was already experienced in the ER when I transferred to another hospital and still felt that way for few months, not feeling really comfortable for about a year. So give yourself some time. Make sure you ask another nurse or the charge for help when you need it. Don't feel bad if you are too busy to help others right away, but do offer to help whenever you have the chance so others know you aren't just taking but willing to give as well. ER is so much about team, and that's one of the things I love about it.

You will denfinitely need to figure out how to organize yourself, but more than any other unit, your organizational plan can go out the window in a heartbeat when you have that diff breather come rolling in the door or your chest pain starts crashing, so knowing how to prioritize will be one of your greatest assets in the ER.

If I tried to memorize anything I'd never remember most of it! I take 2 blank sheets of copy paper (2 for sturdiness) from the printer at the start of the shift, place them together, and fold them twice so that they are in fourths. That size is good for me to right down what I need to remember and also fit in my pocket. If I run out of space on the front and back, I just open up the paper and fold it over for more space. I take a few minutes while getting report to write down my patients names, 2 front and 2 back, along with age, chief complaint, and the treating ER physician's initials. Also any pertinent information, such as labs that are off, when last pain med was given, and what still needs to be done for that patient prior to disposition. I keep it in my pocket so it is handy to write down anything done for the patient so I don't forget to chart anything important.

Some of the skills you learned on the floor are helpful too. Like taking as many things with you when you see a patient as you can anticipate that they will need when you go to see them. If you have a new chest pain come in, you know that they are going to need an EKG, line, labs, connection to monitor, oxygen, blanket, pillow, gown, etc. If any of those things fall to you in your ER, gather them when you first see the patient so you can get them out of the way and you don't have to make so many trips back and forth.

It really does help to keep your patients updated frequently. They are much more likely to be understanding of a longer than expected wait in the ER if they see you regularly and you let them know what is going on and what they are still waiting on.

I'm sure there is tons more that I could tell you but I can't think of anything else right now. Hopefully others will jump in with more suggestions.

Good luck on your new adventure!

jv713 · Sep 3, 2016

thanks for replying! and thank you for such good advice. after my last shift i definitely came to the conclusion that i need to some how make a brain sheet. unlike the floor where i am used to the same team of patients all day (which makes it a lot easier to remember things without writing down)... the fact that its a constant turn over has me completely confused with things i have done, need to get done, or why the patient in room 1 is here in the first place without looking at my computer. i actually came up with something similar to what you have mentioned... i was thinking if i take a paper and fold it into 3-4 columns (our ratio is 1:3-4 depending on the pod we are in)... placing the patients sticker on top of each column. numbering each column per room number. then jotting down info such as cc, hx, sx, meds, allergies, things that i have already done (such as placed a line, drawn labs, ekg), and then write down things i still need to do and cross them out once i have done them. then for their dispo... just cross them out once i know they are discharged or admitted and placing the new patient's sticker on top of the old one. so organize it according to room basically. i hope it works. in my old unit.. all the nurses used the same "Brainsheet" since they were already printed out. but that paper was my life line and kept my day rolling smoothly lol.

but i am slowly starting to kindof see somethings that i can get done before the doc comes in for example like you said.. the pt with chest pain... will definitely need a line, need to be on heart monitor, need labs ect...

another question i have: what if you come into contact with a patient where you have no idea where to start? what questions to ask and correlate to their signs and symptoms... i guess that takes time? learning what questions to ask, and what to anticipate?

GM2RN · Sep 4, 2016

thanks for replying! and thank you for such good advice. after my last shift i definitely came to the conclusion that i need to some how make a brain sheet. unlike the floor where i am used to the same team of patients all day (which makes it a lot easier to remember things without writing down)... the fact that its a constant turn over has me completely confused with things i have done, need to get done, or why the patient in room 1 is here in the first place without looking at my computer. i actually came up with something similar to what you have mentioned... i was thinking if i take a paper and fold it into 3-4 columns (our ratio is 1:3-4 depending on the pod we are in)... placing the patients sticker on top of each column. numbering each column per room number. then jotting down info such as cc, hx, sx, meds, allergies, things that i have already done (such as placed a line, drawn labs, ekg), and then write down things i still need to do and cross them out once i have done them. then for their dispo... just cross them out once i know they are discharged or admitted and placing the new patient's sticker on top of the old one. so organize it according to room basically. i hope it works. in my old unit.. all the nurses used the same "Brainsheet" since they were already printed out. but that paper was my life line and kept my day rolling smoothly lol.
but i am slowly starting to kindof see somethings that i can get done before the doc comes in for example like you said.. the pt with chest pain... will definitely need a line, need to be on heart monitor, need labs ect...
another question i have: what if you come into contact with a patient where you have no idea where to start? what questions to ask and correlate to their signs and symptoms... i guess that takes time? learning what questions to ask, and what to anticipate?

Once you've been in the ER for awhile you will realize that you are repeating many of the same questions over and over and you will get used to what questions to ask for for different complaints. You will sometimes have patients that you won't know if the doc is going to want to start a line and draw labs or not, so I just wait for orders when I get those so I don't do anything unnecessary. But you will always have to do your nursing assessment and you will get a routine after awhile. Even for those questionable times when you aren't sure what the doc will order, you can still have your patient provide a urine sample just in case you need it and that alone will speed up the process and put you ahead of the game. All of this is assuming that you have the time to get things going that soon because there will certainly be times when you are so swamped the entire shift that you many never get to get things going before the doc sees the patient. When you have days like this, just occasionally take a slow deep breath, remind yourself to prioritize the most important things first, and do things one step at a time. Eventually it will all get done even if it's not as fast as you or your patients would like.

I should mention too, in case you haven't figured it out yet, that assessments in the ER are focused and not all patients are head to toe. This may annoy some of the nurses on the floor when you give report but that's the way it goes in the ER. Of course you will have your train wrecks that come in and you will end up doing more or less an HTT assessment out of necessity, but more often it is focused on the chief complaint primarily. I do make sure to document wounds that I happen to see or if the patient or family tells me that wounds are present, but I don't necessarily do a full body skin assessment in the ER.

jv713 · Sep 4, 2016

Yes!! I definitely see exactly what you are saying with the focused assessment. I've learned that with some patients I don't even place my stethoscope on their skin lol let alone MY actual hands. Sometimes the assessment is just a set of questions. My preceptor said it'll take time to know what kind of assessment to perform or what questions to ask but I'm scared I will miss something? Since it's also FOCUSED I wanna make sure I'm focusing on the right thing if that makes sense? For instance.. If a patient comes in with a set of symptoms.. How long will it take me to learn what condition/disease/illness that patient is experiencing in order to help guide my care/assessments/priorities if you know what I mean?

GM2RN · Sep 4, 2016

Yes!! I definitely see exactly what you are saying with the focused assessment. I've learned that with some patients I don't even place my stethoscope on their skin lol let alone MY actual hands. Sometimes the assessment is just a set of questions. My preceptor said it'll take time to know what kind of assessment to perform or what questions to ask but I'm scared I will miss something? Since it's also FOCUSED I wanna make sure I'm focusing on the right thing if that makes sense? For instance.. If a patient comes in with a set of symptoms.. How long will it take me to learn what condition/disease/illness that patient is experiencing in order to help guide my care/assessments/priorities if you know what I mean?

Don't worry about figuring out what their problem is, that's what they are there to find out. What you need to do is ask questions that will help determine what their problem is but it's not up to you to diagnose them. For instance, chest pain may be cardiac related but it could also be other things, like heartburn, muscle strain, stress or anxiety, etc. So you will ask everyone with chest pain pretty much the same questions: where is your pain; does it radiate,; is it reproducible; when did it start; is it constant or intermittent; describe the pain; does it get worse with a deep breath; are you also short of breath; is there anything that you do that makes it better or worse. I will be asking these questions while getting the patient on the monitor and taking a set of vitals. If the answers to their questions lead me and the doc to suspect that it's not heart related, they will still be treated as a cardiac patient with a full workup to rule it out.

Many of the chest pain questions will be the same for any type of pain. For abdominal pain you won't necessarily ask if they are short of breath, but you will want to know about any abdominal surgeries, history of colon problems, last BM, nausea and vomiting, etc. This patient could be anything from appendicitis to bowel obstruction to a bad gallbladder, and you don't have to figure out which one with your assessment, but you will come to learn what your docs will tend to order with this type of patient. They may even do a cardiac workup on this patient depending on where their symptoms and the patients age. But generally speaking, you can expect to start a line, draw blood, get a urine sample, hang fluids, and do a urine preg test on many of your females.

I also happened to come across a post from a newer nurse who has been in the ER now for 10 months and it explained very well what what I felt when I first started in my current position, and still do from time to time, so I'm including it below for you to get another perspective.

I just hit 10 months in the ER as a new grad and had a 12 week preceptorship. I'm far from a seasoned nurse, but I'm not the same RN I was last November.
Those first few weeks/months should feel like a slow motion train wreck, at times. Don't jeopardize patient safety or your safety at any time.
When the taskws started piling up, sometimes I had to "slow down to speed up". Meaning that in order to tackle a mountain of tasks, I needed a quiet moment in the med room to develop a plan of attack. I found that if I slowed down a (tiny) bit, made sure to get the supplies I needed in one trip, was prepared for whatever I was doing, this makes things go so much easier and less stressful. You will be slow getting things together and setting them up but with repetition comes efficiency.
Lots of people on these threads have said that with exposure and experience comes confidence and comfort and at this point I agree. Something clicked around six or seven months for me and every month or so other things click, or at least I notice things fall into place with what feels like less effort or stress. Lots of things happen in what feels almost like automatic mode now.
Until then, you gotta stick out the tough shifts, the terrible patients, the (hopefully occasional) degrading comment and keep asking questions and taking notes and looking things up. Figure out who your pillars are on your shifts, lean on them (but not too much) and learn from them. You'll get it.

GM2RN · Sep 4, 2016

Yes!! I definitely see exactly what you are saying with the focused assessment. I've learned that with some patients I don't even place my stethoscope on their skin lol let alone MY actual hands. Sometimes the assessment is just a set of questions. My preceptor said it'll take time to know what kind of assessment to perform or what questions to ask but I'm scared I will miss something? Since it's also FOCUSED I wanna make sure I'm focusing on the right thing if that makes sense? For instance.. If a patient comes in with a set of symptoms.. How long will it take me to learn what condition/disease/illness that patient is experiencing in order to help guide my care/assessments/priorities if you know what I mean?

Don't worry about figuring out what their problem is, that's what they are there to find out. What you need to do is ask questions that will help determine what their problem is but it's not up to you to diagnose them. For instance, chest pain may be cardiac related but it could also be other things, like heartburn, muscle strain, stress or anxiety, etc. So you will ask everyone with chest pain pretty much the same questions: where is your pain; does it radiate; is it reproducible; when did it start; is it constant or intermittent; describe the pain; does it get worse with a deep breath; are you also short of breath; is there anything that you do that makes it better or worse; have you had any N/V. I will be asking these questions while getting the patient on the monitor and taking a set of vitals. If the answers to their questions lead me and the doc to suspect that it's not heart related, they will still be treated as a cardiac patient with a full workup to rule it out.

Many of the chest pain questions will be the same for any type of pain. For abdominal pain you won't necessarily ask if they are short of breath, but you will want to know about any abdominal surgeries, history of colon problems, last BM, nausea and vomiting, etc. This patient could be anything from appendicitis to bowel obstruction to a bad gallbladder, and you don't have to figure out which one with your assessment, but you will come to learn what your docs will tend to order with this type of patient. They may even do a cardiac workup on this patient depending on their symptoms and the patients age and gender. But generally speaking, for abdominal pain you can expect to start a line, draw blood, get a urine sample, hang fluids, and do a urine preg test on many of your females.

I also happened to come across a post from a newer nurse who has been in the ER now for 10 months and it explained very well what what I felt when I first started in my current position, and still do from time to time, so I'm including it below for you to get another perspective.

I just hit 10 months in the ER as a new grad and had a 12 week preceptorship. I'm far from a seasoned nurse, but I'm not the same RN I was last November.
Those first few weeks/months should feel like a slow motion train wreck, at times. Don't jeopardize patient safety or your safety at any time.
When the taskws started piling up, sometimes I had to "slow down to speed up". Meaning that in order to tackle a mountain of tasks, I needed a quiet moment in the med room to develop a plan of attack. I found that if I slowed down a (tiny) bit, made sure to get the supplies I needed in one trip, was prepared for whatever I was doing, this makes things go so much easier and less stressful. You will be slow getting things together and setting them up but with repetition comes efficiency.
Lots of people on these threads have said that with exposure and experience comes confidence and comfort and at this point I agree. Something clicked around six or seven months for me and every month or so other things click, or at least I notice things fall into place with what feels like less effort or stress. Lots of things happen in what feels almost like automatic mode now.
Until then, you gotta stick out the tough shifts, the terrible patients, the (hopefully occasional) degrading comment and keep asking questions and taking notes and looking things up. Figure out who your pillars are on your shifts, lean on them (but not too much) and learn from them. You'll get it.

TheCommuter, BSN, RN · Sep 4, 2016

Moved to the Emergency Nursing forum.

jv713 · Sep 4, 2016

wow thats great advice thanks so much. this actually eases my nerves because it assures me that i am actually picking up on some type of routine for example, all the questions you said about chest pain.. i find myself asking those exact questions without having to think too hard about what to ask. and that one post is very helpful. that is one complaint i actually said to my preceptor, that i feel super slow and when i try hard to speed up my tasks like getting meds, setting up meds or setting up things i find myself fumbling because i want to be as fast as the seasoned nurses. but i guess like you said... speed will come with time. i work tomorrow and i will have to go to work with a new mind set... that what i am feeling is completely normal and it is okay to be slow at first. thanks so so much :)

GM2RN · Sep 4, 2016

You're welcome! :yes: